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OPD Case Presentation

SANCHEZ, Julienne Rowelie A.


AUP Clinical Clerk ‘19
General Objectives:
To present the case of a patient
suffering from Urinary Tract Infection

Specific Objectives:
 To enumerate the classification of
urinary tract infection
 To determine the appropriate
diagnostics and management of each
type
Demographics
• E.G.V.
• 39 year old Female
• Filipino
• Married
• Born on December 10, 1979
• San Agustin Kanluran, Isla Verde,
Batangas City
• First time to seek consult in our
institution – March 7, 2019
Dysuria

Chief Complaint
History of Present Illness
1 week PTC

Persistence of
Symptoms

• Terminal Dysuria
• Low back pain- 5/10, Consult
intermittent, non-radiating,
non-aggravated.
• No febrile episodes
• No vomiting
• No loss of appetite
• No consult was done
• Patient took sambong capsules
TID for 10 doses- NO RELIEF
Patient is a S/P Dilatation and Curretage-
August 2018
UTI- approx. 2x per year (august 2018) Father- Hypertension
No Hypertension, DM, Heart Disease, Asthma
PTB, COPD, Cancer No known family history of Heart Diseases,uti
Asthma, Pulmonary Tuberculosis, Thyroids
No known allergies to food and drugs. disease, Stroke and Renal Diseases.
No other previous hospitalizations and
surgeries.

LMP: February 20, 2019 Born and raised in Isla Verde, Batangas
G3P2 (2012)
Works as a SPED Teacher
Menarche: 12 years old
Interval: monthly, regular Non-alcoholic beverage drinker
Duration: 4-5 days Non-smoker
Amount: 2 napkins/day Coffee intake of 3 to 4 cups per day
Symptoms: No dysmenorrhea Water intake of approximately 4 glasses per day
Patient had 2 sexual partners. One is previous husband, now separated. No food preference
Presently in monogamous relationship with live-in partner. No dyspareunia.
Daily perineal hygiene 2x a day, use of PH care,
Coitus approximately 1-2x per week.
Contraceptive: Oral Contraceptive pills wipes from front to back
(-) Weight change, Fatigue,
Easy fatigability, Chills, Loss of
Appetite
(-) hematemesis, no dysphagia,
no heartburn, no abdominal
pain, no change in bowel
(-) Rashes, pruritus, habits, no diarrhea, no
discoloration constipation, no melena, no
hematochezia

(-) discharges, no pruritus


(-) headache, vision changes,
dysphagia, colds

(-) seizures, no loss of


(-) cough, DOB, Hemoptysis consciousness, no change of
behavior, no body weakness.

(-) Chest pain, palpitations


PHYSICAL
Patient is awake, conscious,
EXAMINATION coherent, ambulatory, and not in
GENERAL SURVEY
cardiorespiratory distress.

She is of average body built and


height, well groomed.
PHYSICAL
Vital signs
EXAMINATION BP: 120/80 HR: 73 bpm RR: 20 cpm
VITAL SIGNS
T: 36. 2 C O2 sat: 98%

Height: 156 cm Wt: 59.4 kg


BMI: 24.4 kg/m2
PHYSICAL
EXAMINATION
SKIN No pallor, no cyanosis, no
rashes, no lesions, good skin
turgor
Head - Skull is normocephalic. Hair
PHYSICAL distribution normal and with average
texture.
EXAMINATION Eyes - Anicteric sclerae, pink palpebral
HEENT conjunctiva. No conjunctival injections;
Ears – bilaterally symmetrical, non-tender,
no lesions, no foul smelling, no discharges.
Throat – moist oral mucaosa, pinkish
pharynx without exudates and non-
enlarged tonsils with good dentition.
Tongue midline.
Head - Skull is normocephalic. Hair
PHYSICAL distribution normal and with average
texture.
EXAMINATION Eyes - Anicteric sclerae, pink palpebral
HEENT conjunctiva. No conjunctival injections;
Ears – bilaterally symmetrical, non-tender,
no lesions, no foul smelling, no discharges.
Throat – moist oral mucaosa, pinkish
pharynx without exudates and non-
enlarged tonsils with good dentition.
Tongue midline.
PHYSICAL
EXAMINATION No visible neck masses, non-
NECK
distended neck veins, Supple, no
cervical lymphadenopathies No
palpable masses
No lesions, symmetrical chest
PHYSICAL expansion, good inspiratory effort,
tactile fremitus present and
EXAMINATION bilaterally equal.
CHEST/ LUNGS
Lungs are resonant upon percussion
on all lung fields.

Breath sounds vesicular; no rales,


crackles, wheezes or rhonchi. No
adventitious breath sounds.
PHYSICAL No deformities, adynamic
precordium, No heaves, thrills, and
EXAMINATION lifts noted. PMI best at 5th
HEART
intercostal space, midclavicular line.
Normal rate with regular rhythm. At
the base, S2 is greater than S1. At
the apex, S1 is greater than S2.
No murmurs.
PHYSICAL
Flabby, nondistended, normoactive
EXAMINATION bowel sounds, tympanitic on all
ABDOMEN
quadrants, Soft without direct and
rebound tenderness, no palpable
masses and organomegaly noted.
(+) CVA tenderness, bilaterally.
PHYSICAL
EXAMINATION No edema, no clubbing of the digits,
MUSCULOSKELETAL &
EXTREMITIES full and equal pulses, Capillary Refill
<2 seconds. Full range of motions in
all extremities.
Salient Features
 50 y/o
 Female
 Married
 Terminal Dysuria
 low back pain, 5/10, intermittent, non-radiating, non-aggravated
 UTI 2x per year
 Drinks Coffee 3-4 cups/day
 Only drinks 4 glasses of water/day
 Coitus approximately 1-2x per week
 Bilateral CVA tenderness
Differential Diagnosis of
Dysuria
Urinary Tract Obstruction
RULE IN RULE OUT
(+) Terminal Dysuria (-) Hematuria
(+) low back pain, 5/10, (-) Difficulty Voiding
intermittent, non-radiating, (-) change in urinary volume
non-aggravated
(+) Bilateral CVA tenderness

Vaginitis (STI)
RULE IN RULE OUT
(+) Terminal Dysuria (-) Foul smelling vaginal
discharge
(-) vulvar pruritus/ irritation

UTI
RULE IN RULE OUT
(+) Terminal Dysuria Cannot totally rule out
(+) low back pain, 5/10,
intermittent, non-radiating,
non-aggravated
(+) Bilateral CVA tenderness
Diagnostics

Color Light Yellow


Transparency Turbid
Specific Gravity 1.005
pH 5.0
Sugar/Albumin Negative
Pus Cells 30-35
RBC 2-5
Bacteria Rare
Pus in Clamps 5-10
Pregnancy Test Negative
Recurrent UTI
Acute Uncomplicated Pyelonephritis
Initial impression
Urinary Tract
Infection
“common and painful human illness
that, fortunately, is rapidly responsive to modern
antibiotic therapy”
Definition

• Uncomplicated UTI- acute cystitis or pyelonephritis in nonpregnant


outpatient women without anatomic abnormalities or
instrumentation of the urinary tract
• Complicated UTI- encompasses all other types of UTI

Harrison’s Principles of Internal Medicine 19th edition, pp 861


Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Epidemiology

• 1 to 50 y/o- More common in females


• Neonatal period- males higher than females due to higher incidence
of congenital urinary tract anomalies
• After 50 y/o- more common in males than females due to obstruction
from BPH

Harrison’s Principles of Internal Medicine 19th edition, pp 861-862


Risk Factors

• Uncomplicated Cystitis:
use of a diaphragm with spermicide
frequent sexual intercourse
history of UTI

• Pyelonephritis
frequent sexual intercourse
new sexual partner
UTI in the previous 1 2 months
maternal history of UTI
Diabetes
incontinence
Etiology

• usually enteric gram-negative rods that have migrated to the


urinary tract
E. coli (75-90%)
Staphylococcus saprophyticus (5-15%)
Klebsiella, Proteus, Enterococcus, and Citrobacter species (5-10%)

Harrison’s Principles of Internal Medicine 19th edition, pp 862


Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Pathogenesis
Pathogenesis

• Ascent- bacteria establish infection by ascending from the urethra to


the bladder
• Bloodstream- hematogenous spread accounts for <2% of
documented UTIs. (Salmonella and S. aureus)

Harrison’s Principles of Internal Medicine 19th edition, pp 862


Diagnostics
Diagnostic Tools

HISTORY
• At least 1 symptom of UTI (dysuria, frequency, hematuria or back
pain) = 50 % probability
• plus absent vaginal discharge and complicating factors + risk factors
present= 90% probability

Harrison’s Principles of Internal Medicine 19th edition, pp 862


Diagnostic Tools

URINALYSIS
• Nitrite
• Leukocyte Esterase Test
• Pyuria
URINE CULTURE
• “gold standard”

Harrison’s Principles of Internal Medicine 19th edition, pp 862


Harrison’s Principles of Internal Medicine 19th edition, pp 865
Harrison’s Principles of Internal Medicine 19th edition, pp 865
Harrison’s Principles of Internal Medicine 19th edition, pp 865
Asymptomatic Bacteriuria
Asymptomatic Bacteriuria: DEFINITION

• occurs in the absence of symptoms attributable to the bacteria in the


urinary tract and does not usually require treatment
• Incidental findings on urine culture

Harrison’s Principles of Internal Medicine 19th edition, pp 863-864


Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Asymptomatic Bacteriuria: DIAGNOSIS

• WOMEN- two consecutive voided urine specimens with isolation of


the same bacterial strain in quantitative counts ≥100,000 cfu/mL
• MEN- a single, clean-catch voided urine specimen with one bacterial
species isolated in a quantitative count ≥100,000 cfu/mL
• BOTH- a single catheterized urine specimen with one bacterial
species isolated in a quantitative count ≥100 cfu/mL

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update
Asymptomatic Bacteriuria: SCREENING

Screening and treatment for asymptomatic bacteriuria is


recommended in the following:
a. All pregnant women
b. Patients who will undergo genitourinary manipulation or
instrumentation

Routine screening and treatment for asymptomatic bacteriuria is


not recommended for healthy adults.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update
Asymptomatic Bacteriuria: SCREENING

• Screening by urine culture is recommended


• In the absence of facilities for urine culture, significant pyuria (>10
wbc/hpf) or a positive gram stain of unspun urine (>2
microorganisms/oif) in two consecutive midstream urine samples can
be used to screen for asymptomatic bacteriuria.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update
Asymptomatic Bacteriuria: SCREENING

• Urine culture and sensitivity testing are NOT NECESSARY when


urinalysis is negative for pyuria or urine gram stain is negative for
organisms

• Pyuria accompanying asymptomatic bacteriuria is NOT an indication


for antimicrobial treatment among patients for whom screening and
treatment is not recommended.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Asymptomatic Bacteriuria: TREATMENT

• The choice of antibiotic depends on culture results. A seven-day


regimen is recommended

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Asymptomatic Bacteriuria: ALGORITHM
Recurrent UTI
Recurrent UTI: DEFINITION

• diagnosed when a healthy non-pregnant woman with no known


urinary tract abnormalities has:
a. 3 or more episodes of acute uncomplicated cystitis documented by
urine culture during a 12-month period
b. 2 or more episodes in a 6-month period.
Recurrent UTI: TYPES

1. Relapse- occurs when the initial organism persists within the


urinary tract and re-emerges despite adequate treatment usually
occurring 1-2 weeks after stopping treatment
2. Reinfection- occurs when recurrent UTI is caused by a different
bacterial isolate, or by the previously isolated bacteria after a
negative intervening culture or an adequate period (≥2 weeks)
between infections
Recurrent UTI: SCREENING

• Routine screening for urologic abnormalities is not recommended for


the general patient population
Recurrent UTI: DIAGNOSTICS

• Radiologic or imaging studies and cystoscopy are not routinely


indicated in patients with recurrent UTI.

• Renal ultrasound or CT scan/stonogram may be done to screen for


urologic abnormalities
• Patients with anatomical abnormalities should be referred to a
specialist (nephrologist or urologist) for further evaluation.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Recurrent UTI: PREVENTION

• Prophylaxis is recommended in women whose frequency of


recurrence is not acceptable to the patient in terms of level of
discomfort or interference with activities of daily living.
• Antibiotic prophylaxis should be limited to women with recurrent UTI
in whom non-antimicrobial strategies have not been effective and
who prefer prophylactic antimicrobial therapy
• Oral water hydration (2 to 2.5 L/day) may be done to prevent UTI.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Recurrent UTI: PREVENTION

Behavioral Measures
• Post-defecation and anal cleansing antero-posteriorly in women to
avoid contaminating the periurethral area with fecal flora
• Post-coital douche or post-coital urination
• Liberal fluid intake especially after intercourse
• Avoidance of tight-fitting underwear
• Use of alternative form of contraception for women using spermicide-
containing contraceptives
Recurrent UTI: PREVENTION

Cranberry Products
• Cranberry juice and cranberry products
• The recommended dose for UTI prevention is daily
consumption of 300 mL of cranberry juice cocktail or 500
mg capsules containing 36 mg PACs) taken twice a day.
Recurrent UTI: TREATMENT

• Any of the antibiotics for acute uncomplicated cystitis may be used in


the treatment of individual episodes of UTI in women with recurrent
UTI.

• Consider intermittent self-administered therapy in highly educated,


well-informed, motivated patients, wherein the patients are able to
recognize the characteristic signs and symptoms of UTI, are compliant
with medical instructions and have a good relationship with a medical
provider.
Acute Uncomplicated
Cystitis
Acute Uncomplicated Cystitis: DEFINITION

• suspected in premenopausal non-pregnant women presenting with


acute onset of dysuria, frequency, urgency, and gross hematuria;
and without vaginal discharge
• Urinalysis is not necessary to confirm the diagnosis of AUC in women
presenting with one or more of the above symptoms of urinary tract
infection (UTI) in the absence of vaginal discharge and complicating
conditions.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Acute Uncomplicated Cystitis: MANAGEMENT

• Empiric antibiotic treatment is the most cost-effective approach in


the management of AUC.
• Pre-treatment urine culture and sensitivity is NOT recommended.
• Standard urine microscopy and dipstick leukocyte esterase (LE) and
nitrite tests are not prerequisites for treatment.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Acute Uncomplicated Cystitis: ALGORITHM
Acute Uncomplicated Pyeloneph
ritis
Acute Uncomplicated Pyelonephritis:
DEFINITION
• symptomatic infection of the kidneys
1. Mild pyelonephritis can present as low-grade fever with or
without lower-back or costovertebral-angle pain, whereas
2. Severe pyelonephritis can manifest as high fever, rigors, nausea,
vomiting, and flank and/or loin pain.
• Fever is the main feature distinguishing cystitis and pyelonephritis.
The fever of pyelonephritis typically exhibits a high spiking "picket-
fence" pattern and resolves over 72 h of therapy.

Harrison’s Principles of Internal Medicine 19th edition, pp 863


Acute Uncomplicated Pyelonephritis:
DEFINITION
• suspected in otherwise healthy women with no clinical or historical
evidence of anatomic or functional urologic abnormalities, who present
with the classic syndrome of
Fever (T ≥ 38°C)
Chills
flank pain
costovertebral angle tenderness
Nausea and vomiting
with or without signs and symptoms of lower urinary tract infection
(UTI)
• Laboratory findings include pyuria (≥ 5 WBC/HPF of centrifuged urine) on
urinalysis and bacteriuria with counts of ≥10,000 CFU of uropathogen/mL
on urine culture.
Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Acute Uncomplicated Pyelonephritis:
DIAGNOSTICS

Pre-treatment diagnostic tests


• Urinalysis and Gram stain are recommended. Urine culture and
sensitivity test should also be performed routinely to facilitate cost-
effective use of antimicrobial agents and because of the potential for
serious sequelae if an inappropriate antimicrobial agent is used.
• Blood cultures are NOT routinely recommended except in patients
with signs of sepsis.

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Acute Uncomplicated Pyelonephritis:
MANAGEMENT

Indications for admission


• Inability to maintain oral hydration or take medications
• Concern about compliance
• Presence of possible complicating conditions
• Severe illness with high fever, severe pain, marked debility and signs
of sepsis

Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update
Acute Uncomplicated Pyelonephritis:
MANAGEMENT
Acute Uncomplicated Pyelonephritis:
DEFINITION
Complicated Urinary
Tract Infection
cUTI: DEFINITION

• is significant bacteriuria plus clinical symptoms,


which occurs in the setting of:
1. functional or anatomic abnormalities of the
urinary tract or kidneys
2. the presence of an underlying disease that
interferes with host defense mechanisms
3. any condition that increases the risk of
acquiring persistent infection and/or
treatment failure
• The cut-off for significant bacteriuria in complicated
UTI is 100,000 cfu/ml.
cUTI: DIAGNOSTICS

• A urine sample for gram stain, and culture and sensitivity testing
must always be obtained before the initiation of any treatment.
• CT-scan is generally preferred over KUB ultrasound as it can better
identify and localize the presence of urinary tract abnormalities or
multiple lesions such as abscesses
cUTI: TREATMENT
• For mild to moderate illness (symptoms of fever and
lower or upper UTI without urosepsis, circulatory
failure and/or organ dysfunction/failure), oral
fluoroquinolones or amoxicillin/clavulanic acid
• For severely ill patients, broad-spectrum parenteral
antibiotics should be used, choice of which would
depend on the following:
a) The expected pathogens,
b) Results of the urine gram stain,
c) The current susceptibility patterns of
microorganisms in the area, and,
d) Risk factors for the acquisition of drug-resistant
organism
SUMMARY
REFERENCES

• Harrison’s Principles of Internal Medicine 19th edition


• Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults 2013 Update
THANK YOU!